What is the management plan for a patient with low normal left ventricular (LV) systolic function, mild aortic regurgitation, and a left ventricular ejection fraction (LVEF) of 50-55%?

Management of Low Normal Left Ventricular Systolic Function with Mild Aortic Regurgitation

For a patient with low normal left ventricular systolic function (LVEF 50-55%), mild aortic regurgitation, and normal chamber sizes, regular clinical monitoring without immediate surgical intervention is recommended.

Classification and Risk Assessment

The patient's condition can be classified according to the ACC/AHA staging system:

• Stage B (Progressive AR): Mild aortic regurgitation with normal LV systolic function (though at the lower end of normal) 1
• Normal chamber sizes (left ventricle, right ventricle, left atrium, and right atrium)
• LVEF 50-55% (low normal range)

Management Recommendations

Medical Management

1. Blood Pressure Control

   • Treatment of hypertension (systolic blood pressure >140 mm Hg) is recommended (Class I, Level B-NR) 1
   • Goal is to reduce afterload on the left ventricle

2. Clinical Monitoring

   • Regular clinical follow-up every 1-2 years 2
   • Monitor for development of symptoms (dyspnea, angina, syncope)
   • Assess for changes in exercise tolerance

3. Echocardiographic Surveillance

   • Repeat echocardiography every 1-2 years 1
   • More frequent monitoring (6-12 months) if borderline LV function or if there are changes in clinical status
   • Pay particular attention to:
     • LVEF trends
     • LV dimensions
     • Progression of AR severity

Surgical Considerations

Surgery is NOT indicated at this time based on:

• Mild AR severity (not severe) 1
• Normal LV dimensions
• Absence of severe LV dysfunction (LVEF >50%)
• Presumably asymptomatic status

According to the 2020 ACC/AHA guidelines, surgical intervention would only be considered if 1:

• AR becomes severe AND:
  • Symptoms develop
  • LVEF decreases to ≤55% (currently at borderline)
  • LV becomes severely enlarged (LVESD >50 mm or >25 mm/m²)

Perioperative Considerations (If Non-Cardiac Surgery is Planned)

For patients with mild AR and normal LV systolic function undergoing non-cardiac surgery:

• It is reasonable to proceed with elective non-cardiac surgery (Class 2a, Level C-LD) 1
• No special perioperative precautions are required beyond standard monitoring

Special Considerations

Monitoring Parameters

Pay particular attention to these parameters during follow-up:

• LVEF: Currently at low-normal range (50-55%); monitor for any further decline
• LV dimensions: Currently normal; watch for progressive dilation
• AR severity: Currently mild; monitor for progression
• Symptoms: Development of exertional dyspnea, angina, or heart failure symptoms

Potential Pitfalls

1. Underestimation of AR Severity

   • Eccentric jets may lead to underestimation of AR severity, particularly with bicuspid valves 2
   • If clinical suspicion exists, consider additional imaging (TEE, CMR)

2. Borderline LVEF

   • The patient's LVEF is at the lower end of normal (50-55%)
   • This requires closer monitoring than typical mild AR cases
   • Consider more frequent follow-up (6-12 months rather than 1-2 years)

3. Progressive LV Remodeling

   • Even with mild AR, patients with borderline LV function may experience adverse remodeling over time 3
   • Recent research suggests indexed LV end-systolic volume ≥45 mL/m² is associated with worse outcomes 3

Conclusion

The current management strategy should focus on regular monitoring rather than immediate intervention. The low-normal LVEF (50-55%) warrants slightly closer follow-up than typical mild AR cases, but does not currently meet criteria for surgical intervention according to current guidelines.